Biomarkers in EndoVascular Aneurysm Repair (EVAR) and Abdominal Aortic Aneurysm: Pathophysiology and Clinical Implications

Circulating biomarkers have been recently investigated among patients undergoing endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). Considering the plethora of small descriptive studies reporting potential associations between biomarkers and clinical outcomes, this review aims to summarize the current literature considering both the treated disease (post EVAR) and the untreated disease (AAA before EVAR). All studies describing outcomes of tissue biomarkers in patients undergoing EVAR and in patients with AAA were included, and references were checked for additional sources. In the EVAR scenario, circulating interleukin-6 (IL-6) is a marker of inflammatory reaction which might predict postoperative morbidity; cystatin C is a promising early marker of post-procedural acute kidney injury; plasma matrix metalloproteinase-9 (MMP-9) concentration after 3 months from EVAR might help in detecting post-procedural endoleak. This review also summarizes the current gaps in knowledge and future direction of this field of research. Among markers used in patients with AAA, galectin and granzyme appear to be promising and should be carefully investigated even in the EVAR setting. Larger prospective trials are required to establish and evaluate prognostic models with highest values with these markers.

Hybrid coronary revascularization in multivessel coronary artery disease: a systematic review

Aim: Hybrid coronary revascularization (HCR) for multivessel coronary artery disease (CAD) integrates coronary artery bypass grafting (CABG) and percutaneous intervention in a planned revascularization strategy. This systematic review summarizes the state of this art of this technique. Methods: Major databases searched until October 2021. Results: The available literature on HCR includes three randomized trials, ten meta-analysis and 27 retrospective studies. The greatest benefits are observed in patients with low-to-intermediate risk and less complex coronary anatomy; highly complex disease and the presence of risk factors favored conventional CABG in terms of adverse events and survival. Conclusion: HCR is an interesting approach for multivessel CAD but should not be considered a 'one-size-fits-all' procedure. Further studies will specify the subset of patients likely to benefit most from this hybrid approach.

Advanced measurements of coronary calcium scores: how does it affect current clinical practice?

Coronary artery calcium (CAC) scoring has emerged as a marker of the burden of atheromatous disease and has been included in scoring systems. The practice of myocardial revascularization, considering percutaneous procedures or surgical strategies, is dramatically changing over years and the prognostic significance of CAC scoring is gradually being conceived. In this interdisciplinary scenario, vessel specific calcium scoring, mapping of coronary calcification and its integration with functional assessment of coronary artery disease might change the future decisions in the catheterization lab and operative theaters. This article summarizes CAC evaluation techniques and its implications in clinical practice.

Perioperative management after elective cardiac surgery: the predictive value of procalcitonin for infective and noninfective complications

Objective: Procalcitonin (PCT) has been associated with adverse outcomes after cardiac surgery. Nevertheless, there is no consensus on thresholds and timing of PCT measurement to predict adverse outcomes. Materials & methods: A total of 960 patients undergoing elective cardiac surgery were retrospectively evaluated. PCT levels were measured from the first to the seventh postoperative day (POD). The onset of complications was recorded. Results: Complications occurred in 421 (44%) patients. PCT on the third POD was associated with the occurrence of any kind of complications (odds ratio: 1.06; p: 0.037), and noninfectious complications (odds ratio: 1.05; p: 0.035), after adjusting. PCT above the median value at the third POD (>0.33 μg/l) predicted postoperative complications (incidence rate ratio: 1.13; p = 0.035). Conclusion: PCT seems to predict postoperative complications in cardiac surgery. The determination at the third POD yields the greatest sensitivity and specificity.

Development and Test of a Portable ECG Device with Dry Capacitive Electrodes and Driven Right Leg Circuit

The use of wearable sensors for health monitoring is rapidly growing. Over the past decade, wearable technology has gained much attention from the tech industry for commercial reasons and the interest of researchers and clinicians for reasons related to its potential benefit on patients' health. Wearable devices use advanced and specialized sensors able to monitor not only activity parameters, such as heart rate or step count, but also physiological parameters, such as heart electrical activity or blood pressure. Electrocardiogram (ECG) monitoring is becoming one of the most attractive health-related features of modern smartwatches, and, because cardiovascular disease (CVD) is one of the leading causes of death globally, the use of a smartwatch to monitor patients could greatly impact the disease outcomes on health care systems. Commercial wearable devices are able to record just single-lead ECG using a couple of metallic contact dry electrodes. This kind of measurement can be used only for arrhythmia diagnosis. For the diagnosis of other cardiac disorders, additional ECG leads are required. In this study, we characterized an electronic interface to be used with multiple contactless capacitive electrodes in order to develop a wearable ECG device able to perform several lead measurements. We verified the ability of the electronic interface to amplify differential biopotentials and to reject common-mode signals produced by electromagnetic interference (EMI). We developed a portable device based on the studied electronic interface that represents a prototype system for further developments. We evaluated the performances of the developed device. The signal-to-noise ratio of the output signal is favorable, and all the features needed for a clinical evaluation (P waves, QRS complexes and T waves) are clearly readable.

The Use of Radial Artery for CABG: An Update

We used the radial artery as a second target conduit for coronary artery bypass grafting since 1971. However, randomized clinical studies have demonstrated differences in clinical outcomes between the radial artery and other grafts because these trials are underpowered. As we proceed toward 50 years of experience with radial artery grafting, we examined the literature to define the best second-best target vessel for coronary artery bypass grafting. The literature was reviewed with emphasis, and a large number of randomized controlled trials, propensity-matched observational series, and meta-analyses were identified with a large patient population who received arterial conduit and saphenous vein grafts. The radial artery has been shown to be effective and safe when used as a second target conduit for coronary artery bypass grafting. Results and patency rates were superior to those for saphenous vein grafting. It has also been shown that the radial artery is a safe and effective graft as a third conduit into the territory of the artery right coronary artery. However, there is little evidence based on a few comparable series limiting the use of the gastroepiploic artery. In its fifth decade of use, we can finally deduced that the aorto-to-coronary radial bypass graft is the conduit of choice for coronary operations after the left internal thoracic artery to the left anterior descending artery.

Impact of human immunodeficiency virus (HIV) infection in patients undergoing cardiac surgery: a systematic review

The clinical status and prognosis of patients with human immunodeficiency virus (HIV) infection has dramatically changed in the recent years. Cardiovascular diseases can be related to combined antiretroviral therapy and to the aging of HIV-positive population, resulting in significant mortality and morbidity in those patients. It is crucial to understand whether the HIV-status affects the indications and outcomes of cardiac surgery. A literature search was conducted through electronic databases up to 15 May 2020 following PRISMA guidelines. Variables (i.e. patients characteristics) and endpoints (i.e. postoperative complications) were considered as defined in the original publications. All paper describing post-operative outcomes after cardiac surgery were included. Methodological quality of all included studies was assessed using the Newcastle-Ottawa Scale, the Cochrane Risk of Bias tool and the US Preventive Services Task Force grade. A total of eight studies were included in this systematic review; five studies discussed the outcomes of patients with HIV infection, while three studies compared results based on HIV status. All evidences derived from retrospective observational studies with high variability and poor-to-fair quality. Most patients underwent surgical myocardial revascularization. HIV status is not associated with differences in operative mortality (P = 0.32), postoperative mediastinitis (P = 0.30) or pulmonary infective complications (P = 0.67). Cardiac surgery can be considered safe in HIV-positive patients, and HIV status alone should not be considered as a contraindication for cardiac surgery and should not be considered a risk factor for postoperative mortality or perioperative complications. Further studies are required for patients with AIDS.

Sharing of decision-making for infective endocarditis surgery: a narrative review of clinical and ethical implications

Infective endocarditis (IE) is nowadays one of the most challenging disease in cardiac surgery because of its multifaceted clinical and anatomical presentation. Despite the many clinical and surgical advances achieved in the past 60 years, there is a lack of evidence regarding the ideal strategy. The present review aims to investigate and highlight two main novel concepts for the decision-making of the best substitute. Firstly, the concept of an "endocarditis team": a coordinated multidisciplinary effort in the diagnostic work-up, especially in conditions of high risk of embolization or clinical deterioration. A good "endocarditis team" has the role to overcome such problem, in order to ensure a prompt and balanced strategy. Secondly, which ethical considerations are required to drive the choice of valvular substitute. The choice of best valve substitute is a relevant issue of debate, not only with operative but also prognostic and accordingly ethical aftermaths. Many different solutions have been developed to substitute the infected valve. Among these: mechanical prosthesis (MP), biological stented prosthesis (BP), sutureless bioprosthesis and cryopreserved homografts (CHs). Patients need to be informed in detail about the technical issues pertaining the use of these valve substitute. We will discuss the evidences regarding the risk of recurrent infections or future potentially severe calcification of aortic homograft valve and wall (in other words, the failure of the homograft) and the difficulties in managing the reoperation.

Guidelines on prosthetic heart valve management in infective endocarditis: a narrative review comparing American Heart Association/American College of Cardiology and European Society of Cardiology guidelines

Infective endocarditis (IE) represented over the last year a growing medical and surgical concern. The changes in etiology and demographic of the disease, which now includes also a large proportion of iatrogenic conditions, has prompted new studies and updates in the guideline for IE treatment. The increasing use of intravascular and intracardiac devices has introduced new challenges in terms of both antibiotic resistance and surgical treatment of prosthetic endocarditis. Also, patients with complex congenital heart diseases, intravenous drug abusers and patients with chronic renal failure under hemodialysis have been added to the list of high-risk subjects for IE. Important aspects concerning the establishment of the endocarditis team, the clinical management, the optimal medical therapy and the indication and timing for surgery are arguments of debate and controversy across the literature. In particular, the most adequate strategy to be adopted in the context of concomitant neurological complication remains greatly debated. Despite attempts to standardize the practice in IE, the lack of powered randomized clinical evidence prevented the achievement of a univocal consensus in several aspects of the management of IE. This situation reflects in some differences in the recommendation promoted by the European Society of Cardiology and American Heart Association/American College of Cardiology. In this review, we will compare the European Society of Cardiology and the American Heart Association guidelines and discuss important aspects related to clinical management and indications of for treatment.

Systolic Anterior Motion (SAM) Complicating Mitral Valve Repair: Current Concepts of Intraoperative and Postoperative Management

Mitral valve repair is the gold standard for treatment of degenerative mitral regurgitation, such as that caused by leaflet prolapse, flail or annular dilatation. A variety of surgical techniques allow surgeons to achieve a high rate of success with mitral valve repair, even in complex cases, and mitral valve repair is associated with better long-term outcomes than valve replacement. However, in the setting of mitral valve surgical repair, systolic anterior motion (SAM) is a complication that determines the dynamic anterior movement of the mitral valve towards the interventricular septum during systole, and creates a left ventricular outflow tract obstruction associated with residual mitral regurgitation. Awareness of risk factors for SAM influences operative planning for repair. Predictors of SAM are known and can be definitively evaluated with intraoperative transesophageal echocardiography, but SAM still complicates mitral valve repair and, if untreated, negatively impacts short-term and long-term outcomes. A stepwise approach in SAM correction is advocated, consisting of medical therapy with aggressive volume-loading and beta-adrenoceptor blockade, but severe or persistent SAM requires surgical revision with a second cross-clamping or a redo procedure. The correct choice of surgical technique requires a deep understanding of the anatomical substrate of SAM, as SAM can be due to different mechanisms that require tailored surgical correction to avoid ineffective or potentially dangerous procedures. This paper reviews the mechanisms and predictors of SAM and summarizes the current concepts of intraoperative and postoperative SAM management.

Heart Valve Endocarditis

Heart valve replacement is the most common cardiac surgical operation performed worldwide for infective endocarditis (IE). Long-term durability and avoidance of infection relapse are the goals of the procedure. However, no detailed guidelines on prosthesis selection and surgical strategies are available, which should be guided by a comprehensive evaluation of the extent of the infection and its microbiological characteristics, the clinical profile of the patient and the risk of infection recurrence. Conventional mechanical or stented xenografts are the preferred choice for localized heart infection. In cases of complex IE with involvement of the root or the aorto-mitral continuity, the use of homograft is suggested according to the surgeon's and center's experience. The use of homograft needs to be balanced against the risk of structural degeneration. Prosthetic bioroot and prosthetic valved conduit with a mechanical or bioprosthetic valve are also considered acceptable alternatives in patients with aortic valve endocarditis. The further development of preservation techniques to enable the longer durability of allogeneic substitutes is required. We discuss current evidence for the use of valve substitutes in heart valve endocarditis and propose an evidence-based algorithm for the choice of treatment.

Statin treatment and hypertrophic scarring after cardiac surgery

Wound healing process after surgical procedure plays a crucial role to prevent blood loss and infections. Hypertrophic scars might occur after surgery and are generally associated with an inflammatory burden. Cardiac surgery is intrinsically related to a strong systemic inflammatory state that might favor hypertrophic scarring. Besides lipid-lowering effects, statins are known for their pleiotropic and anti-inflammatory activity. The aim of this study was to investigate the impact of statins in the healing process after median sternotomy in patients undergoing cardiac surgery. All patients undergoing major cardiac surgery with median sternotomy and cardiopulmonary bypass, and subsequently evaluated in the outpatient clinic after discharge, were included in this study. A total of 930 Caucasian patients were retrospectively reviewed. At outpatient visit, 276 patients (29.7%) showed the formation of hypertrophic scars. Patients with hypertrophic scars tended to be younger (P = .001) and nonstatin users (P = .001). Logistic regression analysis confirmed the protective role of statins (odds ratio 0.39, 95% confidence interval 0.29-0.53, P = .001), after adjustment for age. A dose-dependent effect was confirmed, showing a more intensive protective effect for higher doses of statins. Statin use might be correlated with reduced hypertrophic scars after cardiac surgery through median sternotomy. A dose-dependent effect has been shown, and statin effect seems to be independent of age in a selected population undergoing surgery with an elevated inflammatory burden. Although further studies are warranted to elucidate the biologic mechanisms, the concept of using statins as anti-scarring agents is novel and should be investigated with tailored studies.

Preventing treatment failures in coronary artery disease: what can we learn from the biology of in-stent restenosis, vein graft failure, and internal thoracic arteries?

Coronary artery disease (CAD) remains one of the most important causes of morbidity and mortality worldwide, and the availability of percutaneous or surgical revascularization procedures significantly improves survival. However, both strategies are daunted by complications which limit long-term effectiveness. In-stent restenosis (ISR) is a major drawback for intracoronary stenting, while graft failure is the limiting factor for coronary artery bypass graft surgery (CABG), especially using veins. Conversely, internal thoracic artery (ITA) is known to maintain long-term patency in CABG. Understanding the biology and pathophysiology of ISR and vein graft failure (VGF) and mechanisms behind ITA resistance to failure is crucial to combat these complications in CAD treatment. This review intends to provide an overview of the biological mechanisms underlying stent and VGF and of the potential therapeutic strategy to prevent these complications. Interestingly, despite being different modalities of revascularization, mechanisms of failure of stent and saphenous vein grafts are very similar from the biological standpoint.

Current diagnostic ECG criteria for left ventricular hypertrophy: is it time to change paradigm in the analysis of data?

BACKGROUND

Twelve-lead ECG represents the most common diagnostic tool in clinical cardiology and allows an immediate screening of left ventricular hypertrophy (LVH), but current criteria might have poor clinical usefulness in everyday clinical practice due to lack of sensitivity.

METHODS

The current study aims to review and compare the clinical performance of known ECG criteria of LVH in a real-life setting; 2134 patients had ECG and echocardiographic exams performed during the same hospitalization. All traces were retrospectively analysed, and the amplitudes of the waves were manually measured. Transthoracic echocardiography was considered as the gold standard to assess LVH.

RESULTS

LVH had a prevalence of 58%. Considering the diagnostic performance of ECG criteria for LVH, the Cornell voltage carried the best area under the receiver operating characteristic curve (0.678), while RaVF (R wave in aVF lead) had the poorer result (0.440). The R5/R6 criterion had the best sensitivity (60%), but with the worst specificity (37.4%). The 'Q or S aVR' had the best specificity (99.9%) but lacks sensitivity (0.80%). The Peguero Lo Presti criterion had a sensitivity of 42.3% and a specificity of 75.8%. The Cornell voltage and the Cornell product had similar area under the receiver operating characteristic curve values which were found to be significantly greater compared with other criteria.

CONCLUSION

Current ECG criteria of LVH have low sensitivity despite an acceptable specificity. Among these, Cornell voltage and Cornell product criteria were equally found to have a more accurate diagnostic performance compared with other criteria. To overcome the intrinsic limitations of the current ECG LVH criteria, a new paradigm in the analysis of electrocardiographic data might be necessary.

Finite Element Analysis Investigate Pulmonary Autograft Root and Leaflet Stresses to Understand Late Durability of Ross Operation

Ross operation might be a valid option for congenital and acquired left ventricular outflow tract disease in selected cases. As the pulmonary autograft is a living substitute for the aortic root that bioinspired the Ross operation, we have created an experimental animal model in which the vital capacity of the pulmonary autograft (PA) has been studied during physiological growth. The present study aims to determine any increased stresses in PA root and leaflet compared to the similar components of the native aorta. An animal model and a mathematical analysis using finite element analysis have been used for the purpose of this manuscript. The results of this study advance our understanding of the relative benefits of pulmonary autograft for the management of severe aortic valve disease. However, it launches a warning about the importance of the choice of the length of the conduits as mechanical deformation, and, therefore, potential failure, increases with the length of the segment subjected to stress. Understanding PA root and leaflet stresses is the first step toward understanding PA durability and the regions prone to dilatation, ultimately to refine the best implant technique.

On-pump beating-heart coronary artery bypass grafting in high-risk patients: A systematic review and meta-analysis

BACKGROUND

Operative technique for surgical myocardial revascularization in high-risk patients remains an argument of debate. On-pump coronary artery bypass graft (CABG) with cardioplegic arrest and off-pump CABG have intrinsic limitations. The hybrid approach of on-pump beating-heart CABG (OPBHC) has been proposed over the years with conflicting results. This systematic review and meta-analysis intends to summarize the contemporary literature.

METHODS

A literature search was conducted through major electronic databases. The systematic review provided a total of 279 articles, of those 17 studies were included in the present study.

RESULTS

Compared with on-pump CABG, OPBHC patients showed a preoperative higher risk profile but had reduced early mortality (risk ratio [RR], 0.59, 95% CI, 0.36-0.97) and reduced postoperative stroke (RR, 0.60, 95% CI, 0.39-0.91). Also, interesting trends towards reduced postoperative intra-aortic balloon pump use (RR, 0.56, 95% CI, 0.31-1.01) and myocardial infarction (RR, 0.48, 95% CI, 0.22-1.07) were observed. Baseline characteristics and postoperative complications were similar between OPBHC and off-pump CABG, but limited data are available. The risk of incomplete revascularization in OPBHC is lower than off-pump CABG (RR, 0.53, 95% CI, 0.33-0.87) but higher than conventional on-pump CABG (RR, 1.71, 95% CI, 1.23-2.39).

CONCLUSION

OPBHC is an effective technique to perform surgical revascularization in high-risk patients as preventing haemodynamic deterioration and guaranteeing adequate end-organ perfusion. OPBHC represents an alternative technique to on-pump and off-pump CABG, in those cases in which complications deriving from cardioplegic arrest or manipulation of the heart are more likely. For these reasons, OPBHC might be useful in patients with recent myocardial infarction or with left ventricular dysfunction.

Antithrombotic treatment in patients with atrial fibrillation undergoing coronary angioplasty: rational convincement and supporting evidence

BACKGROUND

The management of antithrombotic therapy in patients undergoing percutaneous coronary intervention (PCI) with an indication for long-term oral anticoagulant therapy (OAT) is still a matter of debate. We aim to evaluate the safety and the efficacy of dual therapy (DT) compared to triple therapy (TT) in this clinical setting.

METHODS

A study level meta-analysis and a review of randomized trials selected using PubMed, Embase, EBSCO, Cochrane database of systematic reviews, Web of Science, and abstract from major cardiology congresses. Six randomized trials with 12,156 patients evaluating the strategy of DT vs. TT in patients treated with PCI with indication for long-term OAT were included.

RESULTS

Patients treated with DT demonstrated a 45% relative reduction in the risk of TIMI major bleeding (1.71% vs. 2.99%; OR 0.55, 95% CI 0.41-0.71; P<0.0001) and TIMI minor bleeding compared to TT arm (4.67% vs 7.83%, OR 0.55 95% CI 0.39-0.78, P = 0.0007). All-cause mortality was similar in two arms (3.95% vs 3.77%, P = 0.92), as well as cardiovascular mortality (2.21% vs 2.19%, P = 0.97). DT was associated with a borderline increase of ST (1.02% vs 0.67%, P = 0.07). No significant differences were observed in occurrence of MI and stroke.

CONCLUSIONS

Our findings suggest that DT is safer than TT with regard to occurrence of major bleeding. DT with a direct oral anticoagulant plus clopidogrel at discharge could be effective in most patients, maintaining aspirin in periprocedural phase and as longer "tailored" treatment for patients at higher ischemic risk.

A Nomogram for Predicting Long Length of Stay in The Intensive Care Unit in Patients Undergoing CABG: Results From the Multicenter E-CABG Registry

OBJECTIVE

Many papers evaluated predictive factors for prolonged intensive care unit (ICU) stay after cardiac surgery, but efforts in translating those models in practical clinical tools is lacking. The aim of this study was to build a new nomogram score and test its calibration and discrimination power for predicting a long length of stay in the ICU among patients undergoing coronary artery bypass graft surgery (CABG).

DESIGN

Retrospective analysis of an international registry.

SETTING

Multicentric.

PARTICIPANTS

Based on the european multicenter study on coronary artery bypass grafting (E-CABG) registry (NCT02319083), a total of 7,352 consecutive patients who underwent isolated CABG were analyzed.

INTERVENTIONS

A "long length of stay" in the ICU was considered when equal to or more than 3 days. Predictive factors were analyzed through a multivariate logistic regression model that was used for the nomogram.

RESULTS

Long length of ICU stay was observed in 2,665 patients (36.2%). Ten independent variables were included in the final regression model: the SYNTAX score class critical preoperative state, left ventricular ejection fraction class, angina at rest, poor mobility, recent potent antiplatelet use, estimated glomerular filtration rate class, body mass index, sex, and age. Based on this 10-risk factors logistic regression model, a nomogram has been designed.

CONCLUSION

The authors defined a nomogram model that can provide an individual prediction of long length of ICU stay in cardiovascular surgical patients undergoing CABG. This type of model would allow an early recognition of high-risk patients who might receive different preoperative and postoperative treatments to improve outcomes.

Role of autophagy in aneurysm and dissection of the ascending aorta

Maintenance of physiologically balanced levels of autophagy is crucial for cellular homeostasis and in the normal vessel wall, balanced autophagy can be considered a cytoprotective mechanism that preserves endothelial function and prevents cardiovascular disease. Recent studies pointed out the importance of the modulation of the autophagic flux in the pathogenesis of aortic dissection and aneurysms of the ascending aorta. Notably, shear stress (and its receptor p62), IL-6, Rab7 and Atg5/IRE1α pathways of autophagy may be considered the novel super-selective therapeutic target for the preventive and postoperative treatment of aortic aneurysm and aortic dissection. This review intends to summarize current evidences in this field trying to enlighten new avenues for future researches.

Main Risk Factor in Long-Term Postoperative Aortic Root Enlargement After Aortic Valve Surgery Associated with Ascending Aorta Replacement

AIM

Dilatation of the aortic root (AR) after aortic valve surgery associated with ascending aorta replacement (AVS+AAR) is an important concern in long-term follow-up (FU). This study aimed to identify factors that may be associated with this late complication.

MATERIAL AND METHODS

Two-hundred-sixteen consecutive patients (150 males and 66 females) who underwent AVS+AAR from June 2009 to April 2018 at a single center were retrospectively analyzed. The mean trans-thoracic echocardiographic (TTE) FU was 44.9 ± 22.2 months. An increase of 10% in AR size compared to the pre-operative baseline was the outcome variable. The Student t-test or chi-square test was used as appropriate. For a survival analysis, a Kaplan-Meier curve was computed and a log-rank p-value was calculated. Cox's regression model was used to assess the predictive value of variables over time. A p-value < 0.05 was significant.

RESULTS

No significant differences were observed among patients who underwent aortic valve repair and those who underwent aortic valve replacement (log-rank = 0.917). In patients who underwent valve replacement, AR enlargement was associated with the difference between the diameter of the prosthetic valve and the diameter of the straight vascular prosthesis (OR 0.87, P = 0.024). Based on the difference in diameter between vascular and valve prosthesis, we arbitrarily classified the patients into two groups: a small group (S) (n = 52), in which the difference was ≤ 5 mm, and a large group (L) (n = 34), in which the difference was > 5 mm. Significant AR enlargement was observed in 30.8 % of the S group and 14.7 % of the L group (log-rank = 0.026). A difference of more than 5 mm between the aortic valve prosthesis and the vascular prosthesis protected against AR enlargement in the long-term FU (OR 12.31, P = 0.033), even after adjusting for age and sex (OR 00.32, P = 0.043).

CONCLUSION

According to our findings, a difference between the size of the aortic valve prosthesis and the vascular prosthesis of less than or equal to 5 mm was the only factor that increased the risk of AR enlargement after AVS+AAR in long-term FU.

Deep Sternal Wound Infection (DSWI) and Mediastinitis After Cardiac Surgery: Current Approaches and Future Trends in Prevention and Management

Median sternotomy is the most common access for cardiac surgery. Deep surgical wound infection (DSWI) and mediastinitis after median sternotomy remain significant clinical problems after cardiac surgery in terms of mortality, morbidity and healthcare-associated costs. Despite recent advances in medical management and consensus papers, their incidence ranges from 1% to 5%, and the associated mortality ranges from 20% to 50%. Recent studies in this field are providing excellent outcomes with promising results for the near future. The choice of sternal closure technique plays a crucial role in the prevention of DSWI and mediastinitis and should be tailored to the patient's characteristics, as clinical judgement and experience play a pivotal role. Early aggressive surgical debridement, vacuum-assisted closure (VAC) therapy, muscle flap and newer technologies are revolutionizing the paradigm of treatment of DSWI. Also, recent advances in tissue engineering have been refining potential approaches to tissue regeneration or substitution for enhanced wound repair. This editorial aims to briefly summarize the current and future techniques in DSWI prevention and treatment after cardiac surgery.

Inflammatory Response and Endothelial Dysfunction Following Cardiopulmonary Bypass: Pathophysiology and Pharmacological Targets

BACKGROUND

Endothelial injury occurring during cardiopulmonary bypass is a major contributing factor in the development of organ dysfunction, which leads to many of the postoperative complications occurring during cardiac surgery.

OBJECTIVE

This narrative review aims to summarize the main mechanisms of cardiopulmonary bypass - related disease, evaluating the unfavorable events leading to tissue injury, with a description of current pharmacologic and non-pharmacologic mechanisms to reduce CPB-related injury.

METHODS

A Medline/Pubmed/Scopus search was conducted using clinical queries with the key terms "cardiac surgery", "cardiopulmonary bypass", "inflammation" and "endothelial injury", and related MeSH terms, until July 2019. The search strategy included meta-analyses, randomized controlled trials, clinical trials, reviews and pertinent references. Patents were searched using the same key terms from https://patents.google.com/, www.uspto.gov, and www.freepatentsonline.com.

RESULTS

In this review, we discuss the current knowledge of the mechanisms of vascular endothelial cell injury, the acute inflammatory response, and the regulatory factors that control the extent of vascular injury during extracorporeal circulation, summarizing the main target of anti-inflammatory pharmacologic and non-pharmacologic strategies.

CONCLUSION

Inflammatory response and endothelial dysfunction following cardiopulmonary bypass are the prices to pay for the benefits offered during cardiac surgery procedures. Counteracting the detrimental effect of extracorporeal circulation appears to be crucial to improve clinical outcomes in pediatric and adult cardiac surgery. The intrinsic complexity and the tight interplay of the factors involved might require a holistic approach against inflammation and endothelial response.

Are the dynamic changes of the aortic root determinant for thrombosis or leaflet degeneration after transcatheter aortic valve replacement?

The role of the aortic root is to convert the accumulated elastic energy during systole into kinetic flow energy during diastole, in order to improve blood distribution in the coronary tree. Therefore, the sinuses of Valsalva of the aortic root are not predisposed to accept any bulky material, especially in case of uncrushed solid calcific agglomerates. This concept underlines the differences between surgical aortic valve replacement, in which decalcification is a main part of the procedure, and transcatheter aortic valve replacement (TAVR). Cyclic changes in shape and size of the aortic root influence blood flow in the Valsalva sinuses. Recent papers have been investigating the dynamic changes of the aortic root and whether those differences might be correlated with clinical effects, and this paper aims to summarize part of this flourishing literature. Post-TAVR aortic root remodeling, dynamic flow and TAVR complications might have a fluidodynamic background, and clinically observed side effects such as thrombosis or leaflet degeneration should be further investigated in basic researches. Also, aortic root changes could impact valve type and size selection, affecting the decision of over-sizing or under-sizing in order to prevent valve embolization or coronary ostia obstruction.